Wellnet Integrated Care Program – supporting chronic disease management through private public partnerships

Introduction: Public and private funders have a mutual interest in effective chronic disease management at the primary care level due to its potential to reduce hospital admissions. The challenge lies in the complexity of the funding sources in Australia. The government’s Medicare system funds general practice on a fee for service basis, Primary Health Networks (PHNs) are government funded organisations commissioning care within local communities while private health insurers (PHIs) fund hospital care and are not permitted to insure GP services.Change implementation: Sonic Clinical Services (SCS), the primary care division of Sonic Healthcare, has implemented a model of chronic disease management that incorporates a pooled funding approach by private and public funders. SCS has partnered with PHNs and PHIs in a collaborative approach to resource primary care in a way that complements the Medicare fee for service structure.Aim of change: The WellNet Integrated Care Program is a suite of GP-led programs providing targeted and coordinated chronic disease management delivered through a Patient Centred Medical Home model which aims to shift the way patients are managed in primary care. The Medical Home approach shifts the epicentre of health care delivery from the clinician to the patient through a redesign of infrastructure, health care team roles and modes of delivering care. Developed by SCS, its unique elements include:Risk stratification according to level of risk and complexityVoluntary patient enrolmentscdmNet, a web-based platform enabling care planning in real time across the entire clinical teamDedicated nurse care coordinatorChange management supportStepped care approachData analyticsTarget population: There are 5 programs targeting 4 population groups:FeelWell & GetWell - complex multi-morbidityBeWell - multiple morbiditiesStayWell - uncomplicated chronic diseaseLiveWell - at risk of chronic diseaseHighlights: SCS has partnered with Sydney North PHN and 4 PHIs to fund the BeWell program through 5 general practices in NSW. In Victoria, SCS has partnered with Australian Health Service Alliance, a service company representing a number of small to medium size PHIs, to deliver the program through 6 general practices. The start dates for these practices have been staggered with the earliest centre commencing enrolments in February 2017. The early results have included demonstrated improvement in care coordination, patient engagement and achievement of pat